Provider Demographics
NPI:1689963951
Name:BLACKBURN, NICOLE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:PASTEUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5780 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1554
Mailing Address - Country:US
Mailing Address - Phone:404-256-2943
Mailing Address - Fax:
Practice Address - Street 1:5780 PEACHTREE DUNWOODY RD STE 320
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1575
Practice Address - Country:US
Practice Address - Phone:404-256-2943
Practice Address - Fax:404-256-6073
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73617207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology